Shoulder presentations

Question 1

What are the common presentations of shoulder problems?

Answer 1

Pain in neck, shoulder & upper arm
Stiffness in this very mobile joint
Weakness
Instability

Deformity (eg. acromioclavicular joint prominence)
Loss of function

Question 2

What is the pattern of referred pain from gall bladder?

Question 3

What is the problem of shoulder with touching the back or brushing the hair respectively?

Answer 3

Touching the back - internal rotation
Brushing the hair - external rotation

Question 4

What is the time to recovery for shoulder problems?

Answer 4

One year/12 months

Question 5

What are common shoulder problems in primary care?

Answer 5

Rotator cuff problems especially supraspinatus tendonitis (typically ager 35-65) - treatment not very different for inflammation of different muscles in the cuff

Sub-acromial bursitis

Acromioclavicular (joint) disease (trauma in younger adults, arthritis in older)

Question 6

What are common shoulder problems in secondary care?

Answer 6

Frozen shoulder (age 40-60, more common in diabetics)

OA/RA of shoulder

Recurrent dislocation

Question 7

What is supraspinatus tendonitis?

Question 8

What is sub-acromial bursitis?

Question 9

What is frozen shoulder?

Answer 9

Adhesive capsulitis
F>M, 40-60y/o (think OA if above 70)

Question 10

How is frozen shoulder managed?

Question 11

What is rotator cuff tear and how is it managed?

Question 12

How to decide whether to do normal shoulder replacement or reverse shoulder replacement?

Answer 12

Reverse shoulder replacement is done when cuff function is presumably compromised

Question 13

What is the general age presentation of shoulder problems?

Answer 13

20-30s – Instability
30-40s – Impingement
40-50s – Frozen Shoulder
50-60s – Cuff tear
>60 - Arthritis

Question 14

What are the four extrinsic and four intrinsic muscles of the shoulder?

Question 15

Describe the two forms of instability presentation

Answer 15

Acute in Trauma Clinic:
Emergency Department reduction
Painful
In sling

Chronic in Shoulder Clinic:
Atraumatic laxity/subluxations
Not painful
No support

Question 16

Describe anterior and posterior dislocation of the shoulder respectively

Answer 16

Anterior Dislocation:
Common 95%
Traumatic
Sports

Posterior Dislocation:
infrequent 5%
Epileptic fit
Electrocution

Anterior dislocation - externally rotated
Posterior dislocation - internally rotated

Question 17

What are the examination outcomes for instability?

Answer 17

Look – abnormal shoulder contour, muscle wasting
Feel – tenderness, muscle spasm
Move – good ROM, scapular winging/dyskinesia
Tests – RC strength, apprehension, relocation, general laxity

Question 18

With X-rays, what are the two views of shoulder that would be taken?

Answer 18

AP and Garth view (apical-oblique)

Question 19

What are associated injuries of instability?

Question 20

What is the treatment for instability?

Answer 20

Non-operative: physio strengthening of RC, core and scapula stability
*The younger the patient, the higher the risk of recurrent dislocation

Operative:
Arthroscopic stabilisation (eg. repair of Bankart lesion)

Question 21

What is impingement syndrome?

Answer 21

Pain originating from the sub-acromial space

Common and mostly transient

Intrinsic and Extrinsic Causes

Question 22

What are the intrinsic and extrinsic causes of impingement syndrome?

Answer 22

Intrinsic:
Tendon vascularity
Watershed area
Tendon degeneration
Cuff dysfunction

External ‘pressure’:
Type of acromion
Coraco-Acromial ligament
Clavicular spur/osteophyte

Question 23

What are the age group diagnoses of impingement syndrome?

Answer 23

RC Tendonitis/ subacromial bursitis – <30s
Calcific Tendonitis (F>M) - 30-40s
Tendinosis/ partial tears RC - 40-50s
Cuff tear – 50-60s
Cuff arthropathy – 70s

Question 24

What is a ‘painful arc’ in impingement symptom?

Answer 24

For example with flexion of shoulder, pain is felt only at 60-120 degrees (this would be the pain arc)

Question 25

How to treat impingement syndrome?

Question 26

What are presentation characteristics of cuff tears?

Answer 26

Age 50-60s

Acute traumatic/Chronic attrition

Weakness
Pain

Question 27

Describe the examination for cuff tears.

Question 28

What are characteristics of frozen shoulder presentation?

Answer 28

40-50s
More females 1:2
Not uncommonly bilateral (often not simultaneous)
Gradual severe pain
Association w Diabetes, lipid & endocrine disease and Dupuytren’s

Question 29

What is the pathology of frozen shoulder?

Answer 29

Contracture and thickening of coraco-humeral ligament, rotator interval (SSp-SSc), axillary fold (IGHL)

Decrease in joint volume

Not actually adhesion!

Question 30

What is the presentation of frozen shoulder?

Answer 30

Quite sudden onset
Pain at rest
Pain at night
Anterior pain
Stiffness

Global restriction in ROM
External Rotation <50% of normal

Question 31

What is treatment for frozen shoulder?

Question 32

How does glenohumeral arthritis present?

Question 33

State a cause of superior subluxation of humerus

Answer 33

When supraspinatus is torn, the pull of deltoid might lead to superior subluxation of humerus